Arthritic tx in Renal disease

Re: Arthritic tx in Renal disease

James Allsop — Wed, 07 Apr 2010 15:56:00 GMT

as others have mentioned I would have a good discussion about quality of life with the owners and suggest trying NSAID at reduced doses etc. I would be quite happy using cartrphoen and have done so in these cases and have not identified any problems (especially aged renal cats with arthritis 0.1ml per cat weekly for 4 weeks then once monthly ongoing - also facilitates regular check up and improved owner compliance ). If owners are cautious about NSAID the cartrophen is well worth a try.

What about physical therapy - is the dog fit enough for physio or hydro to improve muscle strength?

Re: Arthritic tx in Renal disease

Rajat — Wed, 07 Apr 2010 00:12:59 GMT

Hi there
Few questions - how bad is the CRF and prognosis roughly? Are we looking at making the dog comfy for a month or 6 months?High phos levels? Appetite good/any signs hypergastrinemia/nausea?

I see and tx a lot of these older dogs as I also practice acupuncture.
First things first- acupuncture has no side effects and has been shown to be AS effective as accepted allopathic tx and effective for the tx of stifle OA and back pain in people.
This is very likely to be the case in dogs too (and I can personally testify as can many but I am sure no one wants my dirty empirical evidence !!) - if anyone wants to know more about the scientific basis for acupuncture and why it works please email me happy to talk about it! I would strongly reccommend an acupuncture consult - check out ABVA.co.uk for vets who practise acupuncture.

Secondly I would use NSAIDS unless concerned about nausea and vomitting. The reason is that NSAIDS are relatively contraindicated w/azotemia but more so when volume depletion pre-exists with azotemia, as auto regulation of RBF by COX1 fails. As someone said try previcoz/zubrin or onsior, more cox2 selective. Not fail proof and datasheet still says contra indicated. However moderate doses daily while appetite thirst etc wnl should be fine. I would monitor renal values first few weeks if poss otherwise go by clin signs. I take the same view as many that having the pet comfy is much more important than prolonging life.

Other meds:

Tramadol: min dose 2 max 10mg per kg bid to tid. Note this is a WEAK opioid and its main mecahnism of action is descending noradrenergic/serotonergic inhibition. If this pets pain doesnt include a significant descending lack of inhibition it wont help as much as we want, and can be a relatively weak painkiller by itself. Sedation is an often desired but somewhat misleading benefit as we may think the pet is comfy when its just pased out! which they will often on the higher doses!

Oral codeine/morphine is an option - oral morphine has varying bioavailability in dogs so may need playing with doses. .5-1mg/kg bid to tid is usually enough, >1mg/kg bid to di usually leads to nausea. Morphine much better than codeine.

Fentanyl patches - can be v useful, I am not a fan due to variable absorption (apart from is it stuck properly issues, some dogs dont get adequate analgesia/plasma levels - cant remember which way it goes sorry) and costs but if O can afford and willing to put in the work (care with kids, check patch bid, change every 3-4 days..) they can work very well indeed and fentanyl is an AWESOME analgesic!

Symmetrel : The only other drug (apart from nsaids) shown to help dogs with OA. f this pet had OA for a long time (as most do) then this will likely help. Dose reductions in CRF needed. This works through its NMDA antagonism.

If possible consider hospitalisation and a Morphine/Ketamine +/- Lidocaine CRI for 24-48 hrs and wean off. I often have good responses with this for acute on pain chronic pain. Also allows in clinic assesment of responses and to HIT the pain on the head giving a better chance of success in the end.

IF going for >1 month add high dose fish oils. Simplest to use Go-omega - specifically formulated. anti inflamm effects of EFAs are being investigated for a wide variety of conditions and yes even renal failure ( I think in cats) and been shown to help with reducing numbers of VPCS for eg in boxers w/ARVC.
Otherwise EPA at 40mg/kg and DHA at 20-30mg/kg. Ratio and amounts important. D+ at this rate in a few dogs so can halve dose for a bit if this occurs then increase again.

Cartrophen - works well and good for analgesia. However depends if joints all dried and graty already or if there is any articular cartilage left :) Same regime as others. Off label re NSAIDS but personally I think this is BS and no need to stop NSAIDS unless surgery planned.

Nothing like a bit of muscle to help support those joints so if >4-6 month prognosis consider gentle hydrotherapy + dont forget physical rehab! May be worth a consult with a physio..

If < 1-2 months prognosis I wouldn't bother with EFAs or other supplements just pain meds..Green lipped mussel and glucosamines often help but variable response....use if going > 2 months

I hope this helps - I think we often undertreat these pets and trying to localise pain and 'type of pain' is very important. Someone made the point earlier re OA pain and NSAIDS - I strongly believe OA pain responds to NSAIDs (there is inflammation hence -itis) however chronic neuropathic and other types of pain likely respond poorly and we need other therapies for these...

PS remember acupuncture!!! :) ;)

PPS- for an awesome website on anaesthesia and analgesia check out VASG.org

Cheers

Raj.

Re: Arthritic tx in Renal disease

Bob Russell — Sat, 03 Apr 2010 11:22:48 GMT

Labrador - starting on 1 BID - 60 per month - 600+ per year. Thats a big chunk of the pot. We are a very small practice and only have 3 dogs to my knowledge on them but they feel much better for them. I would almost guarantee that once tried you will think of them as a second line of treatment quite quickly.

Two of the dogs on them were booked in for euthanasia - I suggested a weeks trial - one dog has been on them 18 months now!!

Make no promises to the owner, explain that it is an old drug, may irritate the stomach if not given with food, even say we don't know exactly how they work! I promise they still do!!!!

P.S. I don't work for the drugs company!

Re: Arthritic tx in Renal disease

Michael Woodhouse — Sat, 03 Apr 2010 01:27:41 GMT

[quote user="Robert Russell"]

It is a shame that people seem to forget PLT - it only has 1mg of pred but can make a massive difference to their quality of life. It may be old but it is still a very useful drug. Make sure it is given at the same time as some food.[/quote]

We found that as you have to buy 1000 and they are not really that cheap an option that we stopped stocking them as they went out of date before we got them used (few OOD ones at the back of a cupboard somewhere)!

Re: Arthritic tx in Renal disease

Bob Russell — Thu, 01 Apr 2010 13:19:48 GMT

If a dog is struggling with the 'normal' NSAID's give it a go - you may well be very surprised at the results!

Re: Arthritic tx in Renal disease

Julian Earl — Sat, 06 Mar 2010 14:18:00 GMT

Tramadol does not always work for arthritic pain probably because the anti-inflammatory effect is important even though osteoarthritis is not primarily an inflammatory disease. (FWIW it does not always work very well in people either.) One of the benefits of Tramadol though is that the sedative effect gives a good night's sleep; lack of sleep is a major problem for arthritic people due to the pain being markedly worse at night in the majority of cases. Maybe the same applies to animals?

Overall though, I think the route to go has largely been covered above: try cartrophen, glucosamine, acupuncture, low dose NSAIDs and ultimately euthanasia. Presumably weight reduction is not an issue in your renal patient?

Re: Arthritic tx in Renal disease

Utlendigur — Fri, 05 Mar 2010 22:46:31 GMT

I would probably stick with Tramadol but add in low dose of previcox + appropriate warnings. I must admit to being a bit sceptical of nutraceuticals in the past but having started my own cat on synoquin recently (18yrs old, recovering hyperthyroid, hypertensive, renal insufficiency and quite consistently stiff/sore/lame for months) and seen an incredible response I've changed my mind to some extent. Also, what about hydrotherapy? We've had some very old creaky dogs on verge of pts really benefit (nb they can be a bit worse after first few sessions before the benefits kick in).

Re: Arthritic tx in Renal disease

Hanna Bennett — Fri, 05 Mar 2010 13:22:48 GMT

[quote user="robloxley"]But fundamentally if it's in such pain, the main consideration has to be making it comfortable, and if that reduces it's lifespan it maybe overall better for the dog.[/quote]Quote

Yep, my approach too, certainly warn the owner that you may cause deterioration of the renal disease, but my approach (and it is almost always supported by my clients) is that it is better to have a happy dog for a short time than a miserable one for a long time.

Re: Arthritic tx in Renal disease

Rob Loxley — Thu, 04 Mar 2010 16:14:56 GMT

[quote user="Clive Ansell"]Most practices don't seem to stock PLT, but it is used in some of the practices I work that do petaid charity work.[/quote]
But it's sodding expensive!??

[quote user="Clive Ansell"]I turn to it when other nsaid's have not worked well as it is still a licenced treatment, but I try not to use it first line because of the steroid content.[/quote]
Would you worry at 0.125 mg prednisolone/kg bodyweight?

As for the initial question, I'd try tramadol, possibly buprenorphine (injs or patch) or fentanyl (depending on your policy on dispensind CD2s); consider also neutraceuticals (including Cartrophen and Adequan), maybe trial gabapentin (with care) or maybe a TCA drug.
But fundamentally if it's in such pain, the main consideration has to be making it comfortable, and if that reduces it's lifespan it maybe overall better for the dog.

Re: Arthritic tx in Renal disease

frfluffybottom — Thu, 04 Mar 2010 12:50:11 GMT

Wow- thank you everyone for all the advice..I think I will possibly try on slightly lower dose on NSAIds in conjunction with the tramadol initially..ill keep you posted. Thank you!

Re: Arthritic tx in Renal disease

Hannah Wynne Richards — Thu, 04 Mar 2010 12:04:43 GMT

Well licenced or not, this is one where I would argue vociferously that clinical outcome justifies ignoring the cascade

Wynne

Re: Arthritic tx in Renal disease

Clive Ansell — Thu, 04 Mar 2010 09:53:48 GMT

Doesn't make me sneeze, but usually nurse count tablets not me if I can help it.

Most practices don't seem to stock PLT, but it is used in some of the practices I work that do petaid charity work. I turn to it when other nsaid's have not worked well as it is still a licenced treatment, but I try not to use it first line because of the steroid content.

I have found that some cases of spondylosis respond to PLT better than they do other nsaid's.

Re: Arthritic tx in Renal disease

Hannah Wynne Richards — Thu, 04 Mar 2010 09:41:36 GMT

Clive Your mention of PLT took me back!!!!!!!!!! I haven't used it for about 15 years-does it make you sneeze-counting out tablets was like a pepper spray for me-I suppose I might have been allergic

Wynne

Re: Arthritic tx in Renal disease

Hannah Wynne Richards — Thu, 04 Mar 2010 09:37:53 GMT

Like Emily, off label use of cartrophen-but do get consent. The regime I was told by the rep (and which works-brilliantly ) is the initial licenced regime of 4 injections at 5/7 day intervals, then go onto the same dose every 4 weeks as a top-up. You will need to repeat the initial regime after around 18 months. I combine with nutraceuticals-synoquin or cosequin. j/d is good-my own hip dysplastic lab is on it-rads dreadful, but she bounds around like a kangaroo, but if this one's kidneys are that bad, I would be more inclined to go for renal support diet

I've never used tramadol, but have added codeine to the treatment regime for a few old dogs

Wynne

Re: Arthritic tx in Renal disease

Rudolph — Thu, 04 Mar 2010 09:27:22 GMT

I think low dose NSAIDs plus tramadol would be worth a go. The way I view these cases is that there's little point prolonging the pet's life by preserving kidney function if they are in crippling pain for the duration. NSAIDs may precipitate the onset of overt renal failure and the pet's life may be a bit shorter but at least pain-free.

Re: Arthritic tx in Renal disease

Clive Ansell — Thu, 04 Mar 2010 07:30:04 GMT

I had an old dog recently with severe spondylosis, that has responded very well to maximum dose Tramadol with a low dose of prednisolone (5mg uid for a 35Kg dog). It was found by trial and error really, nsaid's did nothing at all, PLT helped a little, but this combination has helped the dog. This old guy is about 16 and has both renal and hepatic compromise, so he is on borrowed time and pts will not be far away. We just want him to be reasonably pain free in the meantime.

Re: Arthritic tx in Renal disease

Noweia — Wed, 03 Mar 2010 23:04:07 GMT

Tramadol effectiveness seems to depend on the individual. I was on it after thoracic surgery and it didn't make one bit of difference to the pain so I stopped using it; other people I know swear by it.

Forgot to mention acupuncture - I've seen good results with it too.

Re: Arthritic tx in Renal disease

Emily Nightingale — Wed, 03 Mar 2010 23:03:53 GMT

Off label usage of cartrophen in my hands has worked wonders on a cat with renal dz and crippling cervical spine arthritis. Cartrophen dose is 0.03ml/kg. Hope that helps.

Re: Arthritic tx in Renal disease

Gillian Mostyn — Wed, 03 Mar 2010 22:51:39 GMT

I would use an NSAID (by all means pick the least nephrotoxic) and tramadol. I wouldn't be too worried about making the renal problem worse as it sounds like it's quality of life is very poor anyway so will need PTS if the OA is untreatable. I hate seeing dogs crippled with OA - it must be hellish to be in so much pain constantly.

Re: Arthritic tx in Renal disease

Laurence Webb — Wed, 03 Mar 2010 22:41:50 GMT

Tramadol's would be my 1st choice and it should be more potent than NSAIDs anyway, so if it's not working is there more going on? Could the dose be pushed higher?

But as far as drug choice I'd use Paracetemol next (Pardale) in combination with Tramadol if necessary. You can combine it with another NSAID if required. All strictly off-licence of course.

I've not used it much but you could even use amitryptilline if you think there's neurogenic pain.

Complimentary treatments like neutraceuticals would be worth trying but it sounds like the dog's past the point of expecting much from them.

Re: Arthritic tx in Renal disease

Vikki Halliday LLB — Wed, 03 Mar 2010 22:31:19 GMT

I was going to suggest Tramadol, but you appear to have been there. However I have difficulty understanding how it does not appear to help in OA?

Where the dog is suffering acutely from the OA, I'd tend to use a COX2 preferential or selective NSAID, possibly in combination with Tramadol, however you have to make the owner aware of the potential consequences due to the renal impairment, and monitor renal parameters regularly.

You don't say how bad the renal failure is, but I have on occasion treated dogs with some degree of renal compromise with NSAIDs such as Previcox, with Tramadol but both at a reduced dose and advised the owner that it is palliative care, and other than drugs such as Fentanyl patches,( and lots of potential issues with these), we do the best we can until the animal is obviously suffering, when I'm afraid I would recommend euthanasia.

Incidentally, Previcox, Onsior, Zubrin and Tolfedine are also not totally contra-indicated in renal disease, however many of the older NSAIDs are. They would however require monitoring of renal parameters.

Hopefully there may be another pharmaceutical suggestion posted by another member, hope you find a solution!

Vikki

Re: Arthritic tx in Renal disease

Charlotte Marshall — Wed, 03 Mar 2010 22:25:36 GMT

I had a similar situation in a dog which had been on previcox. I referred it for acupunture and the owner felt it really helped and the dog managed without any other pain relief.

Re: Arthritic tx in Renal disease

Noweia — Wed, 03 Mar 2010 22:23:43 GMT

How about Hills J/D? I've known people have been able to stop NSAIDs whilst feeding it, the effect has been so noticeable.